GOODS IN TRANSIT PROPOSAL FORM

Transcription

1 GOODS IN TANSIT POPOSAL FOM This proposal forms the basis of the Insurance contract between the Insured and the Insurer once completed by the Insured and accepted by the Insurer. Making a false statement or withholding any material fact may give the Insurer the right to repudiate any claim made under the policy or may result in the policy being declared null and void from inception, a material fact is any fact which influences the acceptance of the risk or conditions and premiums on which it is accepted. This proposal must therefore be fully/accurately completed and signed by the proposer. INSUED Date of inception (dd/mm/yyyy) Name of insured epresentative / Contact Physical address Tel / Mobile number Company registration number VAT number Have you traded under a different name? Yes (If Yes, specify) How long have you been in operation? DETAILS OF POLICY Most policies are issued on an All isks basis. Please indicate by ticking the box whether you require any of the following special estrictions or Extensions: Fire Collision Overturning & Hijacking only Deterioration of Stock with Incorrect Temperature Setting Excess Buy-Back SASIA FSP Underwritten by Compass Insurance Company Limited Goods In Transit Proposal Form Page 1 of 5

2 Description of goods carried requiring insurance cover: Commodity type Percentage of total Do you carry any of the following high risk Commodities? Copper Cobalt Liquor Tyres Tinned Fish Motor Vehicles F.M.C.G. Electronics What is the maximum load limit required? What is your estimated haulage fee for the next year? How many vehicles in your fleet requiring insurance on loads? Truck tractor igid LDV How many of your rigids / trailers are? Fully enclosed Semi-enclosed Open backed Do you require cover on loads subcontracted to other hauliers? Yes Are your vehicles fitted with any of the following? Device. Of vehicles fitted with device Tachograph: Yes Alarm system: Yes Immobiliser: Yes egistration number on roof: Yes Two-way radio/cellphone: Yes Tracking device: Yes - If yes, specify type of device: FSP Underwritten by Compass Insurance Company Limited Goods In Transit Proposal Form Page 2 of 5

3 In what geographical area is cover required? (Mark those required) South Africa Botswana Namibia Swaziland Zimbabwe Mozambique Zambia Lesotho Malawi Tanzania DC Other (specify) adius of usual operation Short hauls (Max 150km) km Long hauls km Main areas of operation: How many drivers are employed? What pre-employment investigations are carried out? What is your company policy regarding hijacking? What controls are used to ensure safe overnight stops? How many drivers/crew per vehicle? Are escorts used for valuable loads? Yes Any additional comments regarding drivers? Are your loads currently insured? Yes If Yes, please give the name of the Insurer Have you previously had this cover? Yes If Yes, please give the name of the Insurer Please indicate previous uninsured losses/insured claims (before deduction of excess) Date of loss Amount of loss Type of loss FSP Underwritten by Compass Insurance Company Limited Goods In Transit Proposal Form Page 3 of 5

4 Are there any other material facts in respect of the risk proposed which will influence the assessment thereof which should by disclosed? Vehicle fleet list on which cover on loads is required: Vehicle description egistration number Load limit in rands I hereby declare that all statements made herein are true and correct and that there are not other material facts regarding the risk that should be disclosed. I further agree that if any statement or particulars herein supplied by any person other myself, that the person shall be deemed to have been acting as my agent for the purpose of this proposal: Agree: Date Name Signature FSP Underwritten by Compass Insurance Company Limited Goods In Transit Proposal Form Page 4 of 5

5 DEBIT ODE AUTHOITY FOM ACCOUNT DETAILS Account holder Bank Account number Branch code Account type: Cheque Savings Preferred debit date Signed by Capacity We/I request you to draw against my account with the abovementioned bank, the amount necessary for payment of the monthly amount due in respect of the under mentioned insurance on the last day of each and every month commencing on (dd/mmm/yyyy. All such withdrawals from my account shall be treated as though I had signed them personally. Should the bank for any reason reclaim from the Company any of the amounts paid in terms of this request I undertake to refund such amounts to the company. The authority may be cancelled by me by giving thirty days notice in writing, sent by prepaid registered post, but I understand that I shall not be entitled to any refund of any amounts which you have withdrawn while this authority was in force if such amounts were legally owing to you. eceipt of this instruction by you shall be regarded as receipt thereof by my bank. SALIENT ULES On acceptance of this proposal by the Insurer, I/we agree to accept the Transit Underwriting Managers policy wording and its endorsements as issued by them as the contract of insurance between myself/ourselves and Transit Underwriting Managers (Pty) Ltd (TUM). Insurance cover shall only be effected on the official acceptance of insurance by TUM and the issue of a certificate. I/we agree to immediately notify the Insurer or my broker of any change in the material fact of any risk or any change in the circumstances, which may give rise to a claim. The premium is payable monthly in advance. I hereby declare that all the statements made herein are true and correct and that there are no material facts regarding the risk that should be disclosed to Transit Underwriting Managers (Pty) Ltd. Agree: Name Signed Capacity Date Place FSP Underwritten by Compass Insurance Company Limited Goods In Transit Proposal Form Page 5 of 5